Shelton Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Washington.
- Location
- 153 Johns Court, Shelton, Washington 98584
- CMS Provider Number
- 505507
- Inspections on file
- 29
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Shelton Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to protect residents from misappropriation of narcotic medications when concerns about a specific RN’s possible drug diversion and impairment were reported but not investigated or documented by the administrator or DON. An LPN emailed the administrator describing residents stating they had not received medications that were documented as given, the RN appearing impaired, unusual narcotic sign-outs, and discrepancies in narcotic logs, yet no incident report or investigation was initiated at that time. One resident with a hip prosthesis and PRN oxycodone orders reported not receiving an evening oxycodone dose that was documented as administered, resulting in the night nurse withholding oxycodone and giving only Tylenol. Another resident with kidney disease and amputations, who reported never requesting night-time medications except before dialysis, had numerous oxycodone doses documented by the RN during overnight hours. A third cognitively impaired resident had hydrocodone signed out twice within a short interval and twice at the same time on consecutive narcotic log pages, without waste documentation and with only single doses recorded on the EMAR. Staff interviews described the RN nodding off, leaving the floor, and exerting pressure to obtain shifts, while leadership acknowledged receiving diversion concerns but failing to act, allowing discrepancies in narcotic handling to persist.
The facility failed to consistently and accurately reconcile controlled medications, resulting in multiple discrepancies between the EMAR and narcotic logs for three residents receiving PRN narcotic analgesics. One resident with an internal hip prosthesis infection had oxycodone doses documented on the EMAR but not on the narcotic log, and vice versa. Another resident with dementia and a lumbar fracture received oxycodone doses documented only 1 hour and 28 minutes apart despite an order for dosing every 4 hours. A third resident with vascular dementia and spinal stenosis had hydrocodone doses signed out twice within a short interval and twice at the same time on consecutive narcotic log pages, without documentation of waste, while the EMAR reflected only single administrations. The Resident Care Manager confirmed the presence of these documentation discrepancies.
The administrator failed to act on a detailed email from an LPN alleging that an RN appeared impaired at work, was difficult to locate during shifts, and was involved in irregular narcotic documentation, including doses signed out for alert and oriented residents who reported not requesting or receiving them and discrepancies in the narcotic log. The administrator acknowledged observing the RN nodding off but did not complete an incident report, did not document an investigation, and did not ensure the DON was informed. Later, a resident reported not receiving ordered oxycodone when it was documented as given, and another resident, who stated he never requested or received night-time narcotics, had narcotic administrations documented between midnight and early morning by the same RN. These actions and inactions resulted in a breakdown of administrative oversight regarding reporting, investigation, and safeguarding of controlled substances.
A resident with dementia, mild cognitive impairment, and documented verbal, wandering, and aggressive behaviors repeatedly threatened staff, threw objects, attempted to choke a staff member, and left the facility unattended. Over a period of months, progress notes recorded escalating behavioral incidents, yet no behavioral health or psychiatric referrals were documented, despite facility policy directing social services to respond to behavioral symptoms and aggression. An anti-anxiety medication and a care plan intervention referencing PRN mental health referrals were initiated much later, and the DON acknowledged that behavioral health or psychiatric services were not provided even though nursing or social services could have recommended them.
Psychotropic meds were not regularly monitored or documented with specific target behaviors for several residents. Records showed generic behavior monitors, care plans that did not link meds to the behaviors they were intended to treat, missing documentation of non-pharmacological interventions before PRN alprazolam, and inconsistent nursing/CNA charting for residents receiving antipsychotic and antidepressant medications.
Failure to notify the Ombudsman of hospital transfers and an AMA discharge. Three residents with severe cognitive impairment were transferred to the hospital, but the EHR had no documentation that the Ombudsman was notified. A resident with moderate cognitive impairment was discharged AMA, and the resident was omitted from the Ombudsman discharge report because AMA residents were not included.
Incomplete Psychotropic and Guardianship Care Plans: The facility failed to keep resident care plans specific and current for several residents with psychotropic meds, behavioral symptoms, and guardianship needs. Care plans used broad behavior language, listed medication classes that did not match current orders, and did not clearly identify which behaviors were being treated by which meds. For a resident with a guardian, the chart also lacked a care plan for family involvement and information-sharing, and staff/family interviews showed confusion about who could receive updates and attend care conferences.
Antibiotic stewardship was not effectively implemented for two residents reviewed for UTI treatment. One resident received full courses of Bactrim DS and levofloxacin after contaminated urine cultures showed >3 organisms and documentation stated McGeer’s criteria for UTI were not met, with no record that the urine was recollected or that the provider was notified before antibiotics were completed. Another resident received Augmentin for a UTI after a contaminated urine culture, despite later notes showing no dysuria and the infection report stating McGeer’s criteria were not met; staff also acknowledged there was no UA/C&S pending and no known organism susceptibility.
Advance directive documentation was not properly obtained or verified for two residents. Staff scanned POLST forms into the EHR and labeled them as ADs, but the records did not clearly show whether the residents had valid ADs for health care or whether they were informed of their right to complete one. For one cognitively intact resident and one cognitively impaired resident, the chart also lacked clear documentation of requests for POA/AD paperwork or confirmation that the correct documents were on file.
A resident with cognitive impairment and MS was given a perimeter mattress without a prior device evaluation, discussion of risks and benefits, or consent. The resident reported staff removed the standard mattress and replaced it without consulting her, and said the new mattress limited her ability to reach items on the dresser and made her feel stuck in the bed. The DON confirmed there was no documentation showing the required evaluation or consent process was completed.
A resident with moderate cognitive impairment had a lidocaine patch order that was transcribed and carried out as 24-hour continuous use instead of the intended 12 hours on and 12 hours off. The patch was applied daily for 13 administrations, and the resident and multiple nurses stated this was not the correct wear schedule; the DON acknowledged the provider intended only 12 hours of use.
Failure to assess and honor resident food preferences led to meals that did not match ordered diets or stated likes/dislikes. Two newly admitted residents reported no initial food preference interview, cold trays, missing condiments, and diabetic options that were not provided, while another resident with CKD and a soft/bite sized order was served pureed food despite stating they disliked it and had not consented to the change. Staff acknowledged missing butter, lack of alternative menu follow-through, and that food preferences should have been obtained on admission.
Missing Hospice Coordination and Documentation: A resident receiving hospice care had no hospice RN, aide, SW, or chaplain notes in the EHR, and staff could not locate the hospice binder or identify where hospice information was kept. The DON confirmed no one was assigned as the hospice point of contact, while the RN/RCM and LPNs were unable to explain how hospice updates were tracked or documented.
The facility failed to provide adequate supervision and effective fall prevention for several high-risk residents, leading to repeated unwitnessed falls and serious injuries. One resident with dementia and multiple comorbidities had eight unwitnessed bed-related falls; after early falls, staff either implemented limited measures such as a single fall mat or only monitored for latent injuries, and did not add meaningful preventive interventions despite subsequent imaging-confirmed lumbar and facial fractures. Later falls for this resident resulted in additional facial trauma and a laceration requiring sutures, while care plan interventions such as a soft-touch call light were not actually in place at the bedside. A second cognitively impaired resident with metastatic cancer and other conditions experienced numerous unwitnessed falls; post-fall responses often consisted only of monitoring or resident education, and even when 1:1 supervision was ordered, the resident was still observed crawling out of bed. A third resident with hemiplegia, epilepsy, and vascular dementia had multiple unwitnessed falls, with documentation of a bedside commode and fall mat that were not present in the room on observation, and no new interventions were added after repeated falls, despite ongoing fall monitoring.
Multiple residents with complex medical needs did not consistently receive scheduled showers or timely assistance with ADLs due to insufficient nursing staff. Residents and staff reported frequent staffing shortages, missed care opportunities, and delays in call light response and medication administration. Documentation and council minutes confirmed ongoing concerns about missed showers and inconsistent staffing assignments.
A resident with cognitive impairment and multiple health conditions was not afforded privacy during a private conversation, as housekeeping staff remained in the room and cleaned in close proximity despite the resident's discomfort. The resident expressed feeling that staff intentionally intruded, and staff interviews confirmed that privacy should have been respected during such interactions.
A facility failed to obtain physician-ordered lab values for a resident who was hospitalized with sepsis and a UTI. The resident, who was severely cognitively impaired, did not meet hydration needs and lacked consistent monitoring. Additionally, the facility did not follow the bowel protocol for two residents, leading to improper administration of treatments. Staff interviews revealed a lack of policy on vital signs and unmet expectations for documentation.
The facility failed to provide adequate nutritional care for three residents, leading to significant weight loss. One resident lost 14.89% of their weight over six months due to lack of nutritional supplements and improper meal intake recording. Another resident lost 11.09% in 34 days, with their nutritional supplement not implemented. A third resident lost 10.48% over six months, with no alternative meals offered when eating less than 50% of their meal. Staff were unaware of Nutritionally Enhanced Meals (NEM) requirements, and necessary interventions were not implemented.
The facility failed to maintain oxygen equipment and adhere to physicians' orders for three residents. Observations revealed empty humidifier bottles and debris-covered filters on oxygen concentrators. Staff were unclear about responsibilities for equipment maintenance, leading to potential risks for residents.
The facility failed to inform residents and their representatives about their rights regarding binding arbitration agreements. Three residents were not adequately informed about the optional nature of these agreements, their right to rescind within 30 days, and the implications of signing. Staff interviews revealed a lack of proper review and understanding of these agreements during admissions and readmissions.
The facility failed to implement effective infection control measures, as evidenced by staff not following standard precautions for residents with pressure ulcers, urinary catheters, and those on contact precautions. Staff were observed not wearing PPE, not performing hand hygiene, and improperly handling contaminated items, increasing the risk of infection.
The facility failed to transfer funds from resident trust accounts within 30 days after discharge for two residents. One resident was discharged with a $40.00 balance, and another passed away with a $189.51 balance. The Business Office Manager confirmed the delayed account closures, and the Administrator acknowledged the checks were not issued timely.
A resident with cognitive and mental health conditions reported an incident involving a nurse's inappropriate response after a fall, which was not reported or investigated by the facility at the time. The DNS and Administrator acknowledged the failure to report and investigate the incident as required.
The facility failed to accurately assess MDS for four residents, leading to discrepancies in care plans. A resident's MDS did not reflect the use of a Wander Guard, despite documentation and staff confirmation. Another resident's MDS omitted refusals of care, and two residents' MDS assessments failed to identify significant weight loss due to incorrect date usage.
The facility failed to ensure accurate PASRR documentation for three residents. One resident's PASRR omitted diagnoses of MDD and Unspecified Psychosis, another's failed to include a psychotic disorder despite treatment with antipsychotics, and a third resident's PASRR incorrectly listed an anxiety disorder. Staff acknowledged these inaccuracies.
The facility failed to update and accurately reflect care plans for several residents, leading to unmet care needs. A resident with neurogenic bladder had an incomplete care plan, while another required more assistance with oral care than documented. A third resident's wander guard placement was inaccurately recorded, and their nutritional needs were not updated. Additionally, a resident's shower schedule was incorrect, and another's nutrition plan was outdated, lacking interventions for weight loss and food refusal.
The facility failed to provide scheduled bathing assistance to five residents, including those with cognitive impairments and those requiring substantial assistance. Records showed inconsistencies in bathing schedules, with some residents not receiving showers for extended periods. Staff confirmed the lack of adherence to care plans, indicating a deficiency in care.
A facility failed to document pre and post dialysis assessments and medications for a resident with end stage renal disease. The resident had specific orders for dialysis, including midodrine and Ceftazidime administration, but there was a lack of documentation and communication with the dialysis center. This deficiency led to uncertainty about the resident's care and medication administration during dialysis sessions.
The facility experienced a 46.88% medication error rate, with late administration for two residents and omitted medication for another. An RN administered medications late, and an LPN failed to provide a resident's prescribed medication for three days due to unavailability, without notifying the pharmacy or provider.
The facility failed to secure medications properly, with instances of unattended medication on a cart and at a resident's bedside. An RN left a MiraLAX bottle and an unlabeled pill on a medication cart, while an LPN disposed of an unlabeled pill found on the cart. An insulin pen was also left unattended. Additionally, an RN left an insulin pen on a resident's bedside table. These actions did not meet the facility's expectations for medication security.
The facility failed to maintain complete and accurate medical records for three residents, leading to potential risks. A resident's death was not documented, another resident's return from the hospital lacked documentation, and a third resident's pressure ulcer was improperly assessed by an LPN without RN confirmation. Staff acknowledged these documentation gaps, which were against expected standards.
A resident with a full resuscitation order was found unresponsive, and staff initiated chest compressions but failed to provide respirations due to missing equipment. The involved staff had expired CPR certifications, and the facility acknowledged the deficiency, which posed a risk to residents requiring CPR.
The facility failed to ensure timely physician visits within the first 30 days after admission for two residents. One resident with multiple diagnoses did not receive a physician's visit for 112 days after readmission, while another resident with Chronic Systolic Heart Failure did not receive a visit for 50 days. The facility's Administrator and DON acknowledged the issue, citing the facility physician's leave and lack of coverage as reasons for the deficiency.
A resident with dementia and a history of falls experienced an unwitnessed fall resulting in a fracture. The facility did not update the care plan with new interventions to prevent further falls, despite policy requirements. Staff acknowledged the care plan was not revised.
A resident with dementia and depression was allegedly abused by a CNA, who grabbed and slapped the resident. The incident was witnessed by two other CNAs but was not reported until the following day, delaying the investigation and allowing the alleged abuser to continue working.
Failure to Investigate and Prevent Narcotic Diversion Resulting in Misappropriation of Resident Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their narcotic medications and to act on clear allegations of drug diversion by a registered nurse, identified as Staff C. The facility’s abuse and misappropriation policy, updated in March 2025, required thorough investigation of suspected misappropriation, immediate reporting of allegations, and protection of residents from harm. Despite this, an email sent on 02/06/2026 by an LPN (Staff D) to the Administrator (Staff A) reported that several alert and oriented residents stated they had not requested or received medications at times when Staff C documented them as given. The email also described Staff C arriving to work appearing impaired, with head-nodding and difficulty staying awake, narcotics signed out for residents who reported not receiving them, unusual dosing patterns, discrepancies in narcotic logs, and Staff C frequently leaving the building and being difficult to locate. The Administrator acknowledged receiving concerns about Staff C nodding off and personally observing this behavior but only counseled Staff C on staying alert, without initiating or documenting an investigation into the diversion concerns. Resident 1, admitted with an infection and inflammatory reaction due to an internal right hip prosthesis, was cognitively intact, required staff assistance for most activities of daily living, and had an order for oxycodone 5 mg every six hours as needed for pain. Review of the narcotic sign-out log and EMAR showed multiple oxycodone doses documented by Staff C over several days, including entries on 03/21/2026, 03/22/2026, 03/23/2026, and 03/24/2026, with one dose documented on the EMAR but not on the narcotic log. On 03/26/2026, oxycodone was documented as administered at 12:40 AM, 3:24 PM, and 10:00 PM. However, Resident 1 later reported not receiving oxycodone during the evening shift on 03/26/2026, stating she requested pain medication after night-shift care and was told she had already received her “quota” of oxycodone and Tylenol, which she denied. Because the medication was documented as already given at 10:00 PM, the night nurse did not administer oxycodone and instead gave Tylenol. Resident 1 maintained that she had not taken the oxycodone that evening and emphasized that she only wanted medication when she requested it. Resident 2, admitted with chronic kidney disease, diabetes, and bilateral lower extremity amputations, was alert, oriented, and generally independent for most activities of daily living, with an order for oxycodone 5 mg every four hours as needed for pain. EMAR review for February and March 2026 showed that Staff C documented administering oxycodone 10 mg on twenty-two occasions between 11:00 PM and 4:30 AM. In interview, Resident 2 stated he takes medication before going to bed in the evening and does not request or receive medications during the night shift, except when he wakes for dialysis at 5:00 AM on Monday, Wednesday, and Friday. He reported not requesting narcotics during the night, which conflicted with the documented nighttime administrations by Staff C. Resident 3, admitted with vascular dementia and spinal stenosis, was cognitively impaired and received scheduled and as-needed pain medications, including hydrocodone 5/325 mg every eight hours as needed. Review of Resident 3’s narcotic log showed that on 03/02/2026, Staff C signed out hydrocodone at 12:38 PM and again at 2:53 PM, only 2 hours and 15 minutes apart, with no documentation of any wasted dose. The EMAR reflected only the 12:38 PM administration. On 03/25/2026, hydrocodone was signed out by Staff C at 6:01 AM at the bottom of one narcotic log page and again at 6:01 AM at the top of the next page, again without any waste documentation, while the EMAR showed a single administration at 6:01 AM. These discrepancies suggested additional unaccounted-for doses removed by Staff C. Multiple staff interviews further described concerns that were not acted upon in a timely manner. A CNA (Staff H) reported observing Staff C showing signs of impairment, including nodding off, and stated that this had been reported and that the Administrator had come in and seen Staff C in that condition; Staff H also noted that Staff C left the floor for long periods. Another LPN (Staff E) reported that Staff C had inappropriate behavior, including calling or texting to demand that shifts be given up to her. Staff D confirmed by telephone that she had reported concerns in February 2026 to the Administrator about Staff C’s behavior and about narcotics being signed out for residents who normally did not take medications on the night shift. When later asked, the Administrator admitted receiving the February email about possible drug diversion and staff behavior but stated he did not complete an incident report and had no documentation of an investigation, and the DON (Staff B) stated she had no knowledge of the email and had not investigated it. The facility’s later review identified multiple discrepancies related to Staff C’s handling of narcotics, but the initial failure to report, investigate, and act on the early allegations allowed the suspected diversion and misappropriation of residents’ medications to continue from 12/09/2025 through 03/26/2026.
Inconsistent Controlled Substance Documentation and Dosing Intervals
Penalty
Summary
The deficiency involves the facility’s failure to consistently and accurately reconcile controlled medications in accordance with its own controlled substance policy and acceptable standards of practice. The policy required the licensed nurse to immediately document the date and time of administration, amount administered, and nurse’s signature on the narcotic accountability record when removing a controlled dose, and to document administration on the MAR. For one resident with an order for oxycodone 5 mg every 6 hours as needed for pain, the EMAR showed a dose signed out as administered late one evening, but this dose was not recorded on the narcotic log. On another date, a dose was signed out on the narcotic log but not documented on the EMAR. For a second resident with dementia, psychotic disorder, and a lumbar fracture, and an order for oxycodone 5 mg every 4 hours as needed, the narcotic log showed two oxycodone doses administered only 1 hour and 28 minutes apart, contrary to the ordered frequency. For a third resident with vascular dementia and spinal stenosis, and an order for hydrocodone 5/325 mg every 8 hours as needed, the narcotic log showed two hydrocodone doses signed out by the same staff member 2 hours and 15 minutes apart on one date, with no documentation that any medication was wasted, while the EMAR reflected only the first dose. On another date, the narcotic log showed hydrocodone signed out twice at the same time on consecutive pages, again without documentation of waste, while the EMAR reflected only a single dose. The Resident Care Manager acknowledged these discrepancies between the EMARs and narcotic logs.
Failure to Investigate Reported Narcotic Diversion and Safeguard Controlled Substances
Penalty
Summary
The deficiency involves the administrator’s failure to implement and enforce facility policies and procedures for reporting and investigating allegations of narcotic diversion and safeguarding controlled substances after receiving a detailed staff complaint. On 02/06/2026, an LPN emailed the administrator describing multiple concerns about an RN, including that several alert and oriented residents reported they had not requested or received medications at times documented as given, that the RN appeared impaired at work with head-nodding and difficulty staying awake, and that there were specific narcotic-related issues. These issues included narcotics signed out for residents who reported they did not receive them, medications being signed out in 1–2 dose increments at atypical times, and discrepancies in the narcotic log such as medications signed out earlier than allowed and not in accordance with proper documentation procedures. The LPN also reported that the RN frequently left the building during her shift and was difficult to locate. Despite this email, the administrator did not initiate or document an investigation, did not complete an incident report, and did not ensure that the DON was informed of the allegations. The administrator acknowledged receiving the concerns, coming in to observe the RN nodding off, and counseling her about staying alert, but could not provide any documentation of an investigation and believed, without verification, that the DON had checked narcotic counts. The DON later stated she had no knowledge of the February email and had not reported or investigated it. Subsequently, a resident reported not receiving ordered oxycodone on a night shift when it was documented as already administered at 10:00 PM, and another alert and oriented resident stated he did not request or receive narcotics during the night, although records showed the RN had documented administering narcotic pain medication between 12:00 AM and 05:00 AM. These events, combined with the lack of timely reporting and investigation of the initial allegations, led to the cited deficiency in administrative oversight and enforcement of policies related to controlled substances and abuse/neglect reporting.
Failure to Provide Behavioral Health Services for Resident With Repeated Aggressive Behaviors
Penalty
Summary
The facility failed to provide behavioral health services to a resident with documented behavioral symptoms and dementia. The resident was admitted with diagnoses including chronic pain, cellulitis, and dementia, and a quarterly MDS assessment showed mild cognitive impairment, verbal and wandering behaviors, and independence with mobility. Progress notes documented multiple behavioral incidents over several months, including the resident being up most of the night accusing staff of stealing and threatening to run them over with a car, threatening to smash windows to get out of the facility and because they liked the sound of glass breaking, throwing a water pitcher toward staff, attempting to choke a staff member and scratching the staff’s neck, and hitting the staff’s knee with a walker. Additional notes showed the resident’s roommate was removed due to the resident’s behavior, the resident made further verbal threats such as stating they could hit staff, and the resident left the facility unattended and initially refused to return. Despite these documented behaviors beginning in December, the physician did not order an anti-anxiety medication until mid-February, approximately 60 days after the first documented behavior. The resident’s care plan, dated the same day as the medication order, included an intervention for as-needed mental health referrals. However, record review showed no documentation of any referral for behavioral health or psychiatric services, despite the facility’s policy stating that the Social Services Department responds to or makes appropriate referrals for behavioral symptoms and aggression. During interview, the DON acknowledged that the resident had documented behaviors toward staff and visitors and confirmed that the facility did not provide behavioral health or psychiatric services for this resident, even though nursing or social services could have recommended such services.
Psychotropic Medications Not Properly Monitored or Linked to Target Behaviors
Penalty
Summary
The facility failed to ensure psychotropic medications were regularly monitored and documented, including the interventions used, for five sampled residents reviewed for unnecessary medications. Surveyors found that the residents’ records did not consistently identify which target behaviors were associated with each psychotropic medication, and in several cases the behavior monitoring tools used by staff were generic rather than tied to a specific medication or diagnosis. For Resident 6, the record showed orders for alprazolam as needed, duloxetine, and escitalopram, with a care plan for impaired psychosocial well-being that listed behaviors such as anxiety, panic, self-isolation, and refusal of care. However, the care plan did not identify which psychotropic medications the resident was receiving or which target behaviors each medication was intended to treat. The MAR and TAR did not direct nurses to monitor target behaviors for these medications, and the CNA behavior monitor listed many possible behaviors without identifying which were specific to this resident or linked to a particular medication. The resident’s as-needed alprazolam was extended multiple times, but the record did not show provider-documented clinical rationale for each extension, and the February MAR did not identify non-pharmacological interventions to try before administration; the medication was given 23 times that month. For Resident 50, the record showed orders for aripiprazole for psychosis and escitalopram for depression. The psychoactive drug consent left blank the sections for non-pharmacological interventions in use before medication, benefits of medication use, and indication for use or target behaviors. The care plan stated the resident would be monitored for 30 days to establish target behaviors, triggers, and interventions, but it did not identify which medications were being used or what behaviors they were intended to treat. The March MAR did not show target behaviors being monitored, and the behavior monitor used was the same prefabricated form used for Resident 6, without distinguishing which behaviors were targeted by which medication. For Resident 9, the record showed orders for Seroquel for PTSD and venlafaxine for major depressive disorder, but there were no behavior monitors ordered for licensed nursing staff to document behaviors related to either medication. The CNA behavior documentation only included an area for sad/tearful, without identifying which medication or diagnosis that behavior related to. For Resident 45, the record showed trazodone for sleeplessness and prior psychotropic use, but the care plan listed multiple behaviors such as agitation, anger, cursing, hitting, and racial slurs without distinguishing which behaviors were being treated by which medication. For Resident 7, the record showed aripiprazole and venlafaxine for major depressive disorder, but staff described the behavior documentation as the same as used for other residents and not specific to this resident; staff also stated they would only document behaviors in a progress note if they were noteworthy or if the resident was on alert.
Failure to Notify Ombudsman of Hospital Transfers and AMA Discharge
Penalty
Summary
The facility failed to ensure that notification to the Office of the State Long-Term Care Ombudsman occurred for residents transferred to the hospital for 3 of 3 sampled residents reviewed for hospitalization and 1 of 1 resident reviewed for an AMA discharge. Resident 3 was admitted on 07/13/2022 and, according to the Quarterly MDS dated 02/23/2026, was severely cognitively impaired. Resident 3 was transferred to the hospital on [DATE], and the EHR showed no documentation that the Ombudsman was notified of the transfer. Resident 6 was admitted on [DATE], the admission MDS documented severe cognitive impairment, and the resident was transferred to the hospital on [DATE] with no EHR documentation of Ombudsman notification. Resident 67 was admitted on [DATE], the admission MDS documented severe cognitive impairment, and the resident was transferred to the hospital on [DATE] with no EHR documentation of Ombudsman notification. Resident 69 was admitted on [DATE], and the admission MDS documented moderate cognitive impairment. The EHR showed Resident 69 was discharged AMA on 02/22/2026. The Nursing Home Transfer and Discharge Notice documented the resident left AMA and was signed by Staff I, SSA on 03/25/2026. An email from the Administrator stated Resident 69 was not included in the Ombudsman notification because the report run for discharges did not include AMA residents. Staff I later stated they sent the Ombudsman the Nursing Home Transfer and Discharge Notice for Resident 69 on 03/25/2026 and that it was sent late.
Incomplete Psychotropic and Guardianship Care Plans
Penalty
Summary
The facility failed to review, revise, and implement comprehensive care plans for residents with behavioral, psychotropic medication, and guardianship-related needs. The deficiency involved Residents 6, 7, 9, 45, 50, and 54, whose records showed care plans that did not clearly identify resident-specific behaviors, the medications being used to address those behaviors, or the monitoring needed for the medications actually prescribed. Surveyor review and staff interviews confirmed that several care plans used broad, non-specific language and included medication classes or behaviors that did not match the resident’s current orders. Resident 7 had diagnoses of major depressive disorder, moderate cognitive impairment, and required partial to moderate assistance with activities of daily living. The record showed scheduled psychotropic and antidepressant medications, including aripiprazole and venlafaxine. Staff stated the resident had behaviors such as being tearful and sad and that they tried to console and redirect the resident, but the care plan listed behaviors and interventions that were not specific to the resident and did not specify which medications they were for. Resident 45 had diagnoses of anxiety, depression, and restlessness and agitation, and was cognitively intact. The psychosocial well-being care plan listed multiple target behaviors, including agitation, anger, cursing, grabbing, hitting, kicking, screaming, yelling, throwing fecal matter at staff, racist slurs, non-compliance with care, and accusing others. The care plan also listed psychotropic medications as including both an antidepressant/anxiolytic and an antipsychotic, but the record showed the resident was no longer taking an antipsychotic. Staff stated they did not know whether the behaviors were differentiated by medication class and confirmed the care plan should be updated when medication changes occurred. Resident 54 had dementia with severe cognitive impairment and had a guardian. The record showed no care plan related to guardianship or family involvement, and care conferences did not mention family participation. Family members stated they were not included in care conferences and had difficulty obtaining information, while the guardian stated the family could receive information and be present for care conferences. Staff from social services and nursing acknowledged that the family’s involvement and information-sharing should have been care planned and communicated to staff, but it was not. Resident 6 had moderate cognitive impairment, anxiety disorder, and received alprazolam, duloxetine, and escitalopram. The psychosocial well-being care plan directed staff to monitor for anxiousness, panic, self-isolation, refusal of care, and adverse side effects associated with antipsychotic, antidepressant, anxiolytic, and anticonvulsant medications. However, the care plan did not identify which psychotropic medications the resident was actually receiving or which target behaviors each medication was intended to treat, and it included medication classes the resident was not prescribed. Resident 50 had cognitive impairment, depressive disorder, and psychotic disorder, and received aripiprazole for psychosis and escitalopram for depression. The impaired psychosocial well-being care plan instructed staff to monitor for refusals and self-isolation and for adverse side effects associated with antipsychotic, antidepressant, anxiolytic, and anticonvulsant medications. The care plan did not identify which medications the resident was receiving or the target behaviors they were intended to treat, and it also included a medication class the resident was not prescribed. Resident 9 had depressive disorder, PTSD, and moderate cognitive impairment, with orders for Seroquel for PTSD and venlafaxine for major depressive disorder. The care plan identified sad/tearful as the target behavior for the antidepressant, but did not specify any target behaviors for the antipsychotic medication. Staff confirmed the care plan did not differentiate between medication classes.
Antibiotic Stewardship Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program for residents reviewed for antibiotic use. For Resident 80, a urine sample collected in December 2025 was reported as contaminated because greater than three organisms were identified, and recollection was recommended. A Resident Infection Report later documented that the resident denied symptoms of a UTI and that McGeer’s criteria for UTI were not met, but the provider notification section was left blank. The electronic health record showed the resident still completed a full seven-day course of Bactrim DS, and Staff H, the Infection Preventionist, stated there was no documentation that the urine sample was recollected or that the provider was notified before the antibiotic course was completed. Resident 80 had a second episode in January 2026 in which a urine sample again resulted in contamination with greater than three organisms and recollection was recommended. A Resident Infection Report documented pain/discomfort with urination but no further urinary symptoms, stated McGeer’s criteria for UTI were not met, and noted the resident received seven days of levofloxacin despite no documentation that the urine sample was recollected or that the provider was notified before completion of therapy. For Resident 39, a urine sample collected in February 2026 was also contaminated and recollection was recommended. Although progress notes documented dysuria initially, later notes documented denial of dysuria, and the Resident Infection Report stated McGeer’s criteria for UTI were not met while also noting the resident was treated with a seven-day course of Augmentin based on Loeb criteria even though Staff H acknowledged there was no UA with C&S pending and no knowledge of the causative organism or susceptibility to Augmentin.
Advance Directive Documentation Not Properly Obtained or Verified
Penalty
Summary
The facility failed to implement a system to ensure that advance directives were requested or obtained on admission and that residents without advance directives were given written information about and informed of their right to formulate one. This deficiency was identified for 2 of 4 residents reviewed for advance directives, Resident 11 and Resident 8, and was cited under WAC 388-97-0300 (1)(b), (3) (a-c). Resident 11 was admitted to the facility and was cognitively intact on the 03/18/2026 MDS. The EHR contained a document labeled Advanced Directive in the miscellaneous section, but the document was a POLST form rather than an advance directive for health care. A care conference note dated 12/24/2025 showed staff checked that an advance directive was reviewed, but the record did not document whether Resident 11 had an advance directive for health care or whether the resident was informed and given written information about the right to formulate one. Resident 8 was admitted to the facility and was cognitively impaired on the significant change MDS. The EHR also contained a document labeled Advanced Directive that was actually a POLST form. A care conference note dated 12/08/2025 showed staff checked that an advance directive was reviewed, and documented that POA paperwork was discussed with the daughter, who said her sister had previously started the POA for health care process and may have the paperwork. The record did not show attempts to contact the other daughter to determine whether POA for health care paperwork had been completed or to request a copy of the document.
Failure to Assess and Obtain Consent Before Perimeter Mattress Use
Penalty
Summary
The facility failed to ensure that a potential restraint was assessed for safety, that the risks and benefits of the device were discussed with the resident and/or representative, and that consent was obtained before the device was used for Resident 6. The facility’s policy stated that before a physical or mechanical device was implemented, a device evaluation would be completed and the risks and benefits would be discussed with the resident and/or representative, with consent obtained. The report identified that staff did not complete a device evaluation, did not explain the risks and benefits of the perimeter mattress, and did not obtain consent before it was placed in the resident’s room. Resident 6 was admitted to the facility and, on the Quarterly MDS dated 02/09/2026, was documented as cognitively impaired, with MS, and requiring partial/moderate assistance to roll left and right in bed and to move from lying to sitting at the edge of the bed. The resident reported that staff removed the mattress from her bed and replaced it with a perimeter mattress without discussing it with her or obtaining her consent. The resident stated that with the standard mattress she could roll to the edge of the bed and reach items on the dresser, but after the perimeter mattress was placed she could no longer reach those items and had to call staff whenever she wanted to get or return an item. Staff B, DON, stated that a device evaluation should have been completed and the risks and benefits discussed before implementation, and confirmed there was no documentation showing that any of those steps had been done.
Unnecessary prolonged lidocaine patch use
Penalty
Summary
The facility failed to ensure that Resident 19’s drug regimen was free from unnecessary medication related to excessive duration. Resident 19 was admitted to the facility and the admission MDS dated 03/05/2026 showed the resident was cognitively moderately impaired. The resident had a current order for a lidocaine patch, ordered on 03/05/2026, and beginning on 03/08/2026 the order directed staff to remove the patch at 8:59 AM and apply it at 9:00 AM. Record review showed the lidocaine patch was applied from 03/08/2026 through 03/21/2026 for 13 total administrations of 24 hours each, with the patch applied and removed the following day before a new application. During interviews, Resident 19 stated staff were putting the patch on for 24 hours at a time and then taking it off and immediately putting another one on, which the resident said was not how it should be done. Staff D, an RN, stated lidocaine patches should only be on for about 12 hours at a time, and Staff C, the Resident Care Manager/RN, said the patch should be worn for 12 hours and then off for 12 hours and that Resident 19’s order was transcribed incorrectly by nursing. Staff B, the DON, also stated the standard continuous wear time was 12 hours and acknowledged the provider’s intent was for only 12 hours of use.
Failure to Assess and Honor Food Preferences
Penalty
Summary
The facility failed to assess resident food preferences and failed to provide food that matched resident preferences for three residents reviewed for food services. The report states these failures placed residents at risk for hunger, nutrient deficiency, and diminished quality of life. The cited regulatory references were WAC 388-97-1120(2)(a), -1100(1), and -1140(6). Resident 75 and Resident 76, both recently admitted, reported that no one had discussed their food preferences with them when they first arrived. Resident 75 said they had not been able to eat most of the food because they were supposed to be on a diabetic diet, and their breakfast tray included pancakes with packaged syrup, sausage, and packaged brown sugar. Resident 75 ate one pancake without syrup, half the sausage, and did not open the brown sugar, stating they did not like pancakes or sausage and had asked for sugar free syrup but was told the facility did not carry it. Resident 76 said the food was often cold and that half the time they did not eat it because they did not know what it was and no alternatives had been provided. On the following day, Resident 75 said the Dietary Manager had only recently interviewed them and their roommate about food preferences and had documented likes and dislikes, but the promised alternative menu had not been brought back. Resident 75’s breakfast tray contained only an English muffin with two sugar-based jellies and no butter or other foods, and Resident 75 said they needed protein such as cheese or cottage cheese to have strength for physical therapy. Resident 76’s tray contained an English muffin and one piece of bacon with no butter or jellies, and Resident 76 said they had eaten only the bacon. A CNA confirmed that butter should have been offered with the trays, but neither resident had butter on their plates and the CNA did not return to offer it or any alternative. Resident 75’s lunch tray contained pasta, a breadstick, cauliflower, and a banana, and Resident 75 said they did not eat bananas and that the meal had too many carbohydrates for them. Resident 75 said they needed protein and would have preferred the alternative meal but had never been asked. Resident 11, who had chronic kidney disease and was independently able to make decisions, reported that food tasted like mud because of their kidney disease and that the facility was pureeing food even though they could have soft food. Their meal ticket showed soft and bite sized food, but observations showed meals with some diced or mashed items and the rest of the plate pureed. Resident 11 said they disliked pureed food, had told staff from day one they would not eat it, and did not know where the pureed orders came from. The record showed the last food preference evaluation for Resident 11 was dated 12/01/2025 during a previous stay, and staff acknowledged that food preferences should have been obtained on admission.
Missing Hospice Coordination and Documentation
Penalty
Summary
The facility failed to designate a member of its interdisciplinary team who would be responsible for working with hospice representatives to ensure effective coordination of care between the facility and hospice staff, and it also failed to maintain documentation in the resident’s EHR showing when hospice disciplines participated in care and what care was provided. Resident 3 was admitted to the facility and, on the quarterly MDS dated 02/23/2026, was documented as severely cognitively impaired and receiving hospice services. A hospice plan of care dated 01/13/2026 indicated the resident was to receive hospice RN visits twice weekly, hospice aide visits twice weekly, social worker and chaplain visits per resident preference, and wound care each visit, beginning 12/26/2025. Resident 3’s EHR contained no hospice RN, hospice aide, social worker, or chaplain visit notes or updates. During the survey, staff were unable to locate Resident 3’s hospice binder at the nurses’ station or explain where hospice information was kept in the EHR. The DON, LPN, and RN/RCM stated the hospice agency did not have binders, and the DON confirmed the facility did not have the hospice documentation. The RN/RCM reported she had just contacted the hospice agency to request the paperwork, and the DON stated no one was currently assigned as the facility’s point of contact for the hospice agency, although it had previously been an LPN.
Failure to Implement and Maintain Effective Fall Prevention and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for multiple residents assessed as high fall risk, resulting in repeated unwitnessed falls and injuries. Facility policy required licensed nurses to update care plans with individualized interventions to reduce or prevent falls, to review care plans after each fall to determine intervention effectiveness, and to complete a systematic post-fall review with root cause identification. The policy also stated that while a new intervention was not required after every fall, each fall required review of current interventions and consideration of discontinuing ineffective ones. Despite this, residents with high fall risk scores experienced numerous unwitnessed falls where either no new preventive interventions were implemented, or interventions documented in the care plan were not put into place. One resident with dementia, seizures, atrial fibrillation, cognitive impairment, and dependence on staff for transfers had a fall risk score of 105 and sustained eight unwitnessed falls from their bed. After an unwitnessed fall on 10/26/2025, the only intervention documented was placement of a fall mat. Following another unwitnessed fall on 11/27/2025, the intervention was limited to lab testing and urinalysis. After a fall on 11/30/2025, the facility documented only monitoring for latent injuries and did not implement any new intervention to prevent further falls. Subsequent imaging on 12/03/2025 revealed an acute to subacute L2 vertebral body fracture and multilevel compression fractures, and the resident reported severe sharp, stabbing back pain. On 12/12/2025, the resident had another unwitnessed fall when attempting to get out of bed to use the toilet, resulting in facial trauma with bleeding from the right nostril and mouth, headache, and back pain; hospital CT imaging showed acute maxillofacial fractures involving the right orbital wall and floor, right maxillary sinus walls, and associated edema and hematoma. The same resident continued to experience additional unwitnessed falls after these injuries. Later on 12/12/2025, the resident had another unwitnessed fall in their room, striking their face and having blood in the nostrils; the only new interventions documented were a pharmacy review and a bedside commode. On 12/25/2025, the resident had an unwitnessed fall in their room without injury, and staff documented education to wait for assistance, despite the resident’s cognitive impairment; the care plan revised on 12/26/2025 showed no new supervision intervention. After another unwitnessed fall on 12/26/2025 with a bruised left knee, the care plan was revised on 12/29/2025 only to add a soft-touch call light. Following an unwitnessed fall on 01/06/2026 with a laceration above the right eyebrow requiring hospital evaluation and sutures, the resident’s room was changed to increase supervision. However, subsequent observations on 01/14/2026 and 01/15/2026 showed the resident using a regular call bell instead of the soft call light specified in the care plan, and an LPN acknowledged the resident did not have the soft call light in place. Another resident with prostate cancer with metastasis, diabetes, bipolar disorder, severe cognitive impairment, wheelchair use, incontinence, and a fall risk score of 65 had 11 falls without injury over a short period. After an unwitnessed fall on 11/25/2025, the only intervention was to monitor for latent injuries. Following an unwitnessed fall outside the dining room on 11/28/2025, after staff had placed the resident outside the dining room post-meal, the intervention was to provide training to the resident to stay in the dining room, despite the resident’s severe cognitive impairment. Later that same day, the resident had another unwitnessed fall from bed, and no new intervention was implemented to prevent further falls. After an unwitnessed fall near the nursing station on 12/19/2025, the DON reported that the intervention was to place the resident on 1:1 supervision; however, on 12/20/2025, while on 1:1 supervision, the resident was observed crawling out of bed. The DON acknowledged that the resident had multiple falls during this period and that education was not an appropriate intervention given the resident’s cognitive impairment. A third resident with hemiplegia, hemiparesis, epilepsy, vascular dementia, cognitive impairment, wheelchair and walker use, incontinence, and a fall risk score of 55 had five falls without injury. After an unwitnessed fall on 12/30/2025 in the resident’s room, the documented intervention was a bedside commode. Following another unwitnessed fall on 01/12/2026 in the room, no new intervention was implemented to prevent further falls, and documentation only noted that a fall mat was placed at the bedside. After a subsequent unwitnessed fall on 01/14/2026, documentation again showed no new intervention, stating only that the resident was already on fall monitoring. During observation on 01/16/2026, the resident was found resting in bed without a fall mat or bedside commode in the room, and an LPN acknowledged that these items were not present despite being documented as interventions. The administrator and DON later acknowledged that residents had falls with injuries and that new fall interventions were not implemented after falls for these residents, even though facility policy required review of falls and interventions.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident interviews, record reviews, and staff schedules. Several residents with varying medical conditions, including dementia, diabetes, post-traumatic stress disorder, asthma, chronic pain, major depressive syndrome, spinal stenosis, chronic obstructive pulmonary disease, stroke, and pressure ulcers, did not consistently receive scheduled showers or timely assistance with activities of daily living (ADLs). Documentation showed that residents often missed scheduled bathing opportunities, and staff did not always reattempt or document refusals as required by care plans. Residents reported long waits for call light responses, late medication administration, and staff rushing through care tasks. Some residents specifically noted that showers did not occur on their preferred or scheduled days, and that staff did not spend adequate time with them. Observations included residents appearing disheveled and in poor hygiene, with visible sores and scabs. Resident council minutes and grievance forms further documented ongoing concerns about short staffing, inconsistent assignment of nursing assistants, missed showers, and lack of communication regarding medication needs. Staff interviews confirmed that staffing shortages were frequent, with bath aides (BAs) often being reassigned to cover other shifts, leaving nursing assistants (NAs) responsible for both floor duties and showers. Staff described feeling overwhelmed and unable to complete all required care, particularly when high-acuity residents were present or during periods of increased absenteeism. Leadership acknowledged the ongoing issues with staffing and the impact on resident care, including missed showers and delayed medication passes.
Failure to Respect Resident Privacy During Private Conversation
Penalty
Summary
Staff failed to honor a resident's right to privacy and dignity during a private conversation. The resident, who had dementia, post-traumatic stress syndrome, and diabetes mellitus, required substantial assistance with activities of daily living and was dependent on staff to meet emotional, intellectual, physical, and social needs. During an interview with the resident, housekeeping staff remained in the room, cleaning in close proximity to the resident and the interviewer, despite the resident's expressed discomfort and request for privacy. One staff member stood at the entrance while another cleaned around the resident's bed and bedside table, and only moved to the bathroom after being asked by the resident. The resident reported feeling that staff intentionally intruded to overhear conversations and described the behavior as uncaring and lacking empathy. Staff interviews confirmed that housekeeping staff should respect residents' privacy when they have guests and that cleaning should not occur near residents during private conversations. The Director of Nursing Services acknowledged the privacy issue, stating that staff should not have been cleaning near the resident and interviewer during their discussion.
Failure to Follow Physician Orders and Bowel Protocol
Penalty
Summary
The facility failed to ensure physician-ordered laboratory values were obtained for a resident who was declining, found unresponsive, and had to be hospitalized. This resident, who was severely cognitively impaired and dependent on staff for care, was admitted with diagnoses including epilepsy and surgical aftercare following genitourinary surgery. Despite being placed on a fluid restriction and a no added salt diet, the resident did not meet their daily hydration needs for 8 out of 10 days. The facility did not obtain a urinalysis or complete blood count as ordered, and there was a lack of consistent monitoring and documentation of the resident's condition. The resident was eventually found unresponsive with abnormal vital signs and was hospitalized with a urinary tract infection and sepsis. The facility also failed to follow the bowel protocol for two residents. One resident did not have a bowel movement for 10 days, and the facility administered an enema out of order from the bowel protocol without documenting the results or any refusals of less invasive treatments. There was no alert charting or documentation regarding the lack of bowel movement or the intervention of the enema. Another resident did not receive Milk of Magnesia as ordered on the fourth day without a bowel movement, as per the bowel protocol. Interviews with staff revealed that there was no policy on vital signs, and expectations for alert charting and documentation were not met. The Director of Nursing Services acknowledged that the facility did not prevent the hospitalization by failing to obtain the necessary laboratory tests. The Resident Care Manager confirmed that the bowel protocol was not followed, and there was a lack of documentation and alert charting for the residents involved.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to ensure proper nutritional care for three residents, leading to significant weight loss and potential harm. Resident 14 experienced a severe weight loss of 14.89% over six months, with the facility failing to provide nutritional supplements as ordered, accurately record meal intake, and obtain weekly weights despite clear indicators of nutritional decline. Observations showed that Resident 14 was not provided with whole milk as part of their Nutritionally Enhanced Meals (NEM) diet, and staff were unaware of the NEM requirements. The resident's significant weight loss was not effectively addressed, and interventions were not reassessed for effectiveness. Resident 49 experienced an 11.09% weight loss in 34 days, which went unidentified by the facility staff. The resident's nutritional supplement, Ensure Plus, was not transcribed or implemented, and the resident was not reviewed in the facility's weekly nutrition meeting due to the absence of the Registered Dietician. Observations revealed that the resident was not provided with the NEM diet, and staff did not recognize the significance of the weight loss or implement necessary interventions. The resident's lack of appetite was not adequately addressed, and there was no follow-up on nutritional recommendations. Resident 29 experienced a 10.48% weight loss over six months, with the facility failing to provide the prescribed NEM diet and calorie-dense supplements. Observations showed that the resident was not offered alternative meals or supplements when eating less than 50% of their meal, contrary to the care plan. The resident's weight loss was not identified or addressed by the facility, and there was a lack of communication with the resident's Power of Attorney regarding the weight loss and dietary needs. Staff were unaware of the NEM diet requirements, and the facility did not document or implement the necessary interventions to address the resident's nutritional needs.
Failure to Maintain Oxygen Equipment and Adhere to Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents by not adhering to physicians' orders and neglecting the maintenance of oxygen equipment. Resident 51 was observed receiving oxygen at incorrect flow rates and using an oxygen concentrator with a filter covered in debris and an empty humidifier bottle. The staff did not have orders or directions to check or replace the humidifier bottle or clean the concentrator filter, and the Resident Care Manager was unaware of who was responsible for these tasks. Similarly, Resident 32 was found with an empty humidifier bottle and a heavily matted filter on their oxygen concentrator. Staff members were unaware of the need to clean the filter, indicating a lack of clarity regarding responsibilities. Resident 38 also had an empty humidifier bottle, and there were no orders to check or replace it. The Director of Nursing later stated that staff should clean the concentrator filters weekly, but this was not being done, leading to potential risks for the residents involved.
Failure to Inform Residents of Arbitration Agreement Rights
Penalty
Summary
The facility failed to ensure that residents or their representatives were adequately informed about the binding arbitration agreements they were signing. This deficiency was identified for three residents who were reviewed for binding arbitration agreements. Resident 32 was unaware that signing the agreement meant giving up the right to litigation in court and believed signing was mandatory for admission. Resident 51 did not remember signing the agreement and was not informed about the option to terminate or withdraw from it within 30 days. Resident 54's Power of Attorney (POA) was not aware of the implications of the agreement, including its applicability to future admissions and the right to rescind within 30 days. Staff interviews revealed that the facility's process for reviewing arbitration agreements was inadequate. Staff V, responsible for admissions, indicated that arbitration agreements were reviewed within 72 hours of admission, but there was no specific process to ensure residents or their representatives understood the agreements. The facility relied on the assumption that if someone was designated as a POA, they were capable of understanding the agreement. Additionally, during readmissions, the facility did not re-review the arbitration agreements, assuming prior consent was still valid. The facility administrator expected residents or their representatives to be fully aware of the optional nature of the agreements and the 30-day rescission period, but this expectation was not met in practice.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) as evidenced by multiple instances of non-compliance with standard precautions, enhanced barrier precautions, and transmission-based precautions. For Resident 13, who was severely cognitively impaired and dependent on staff for care, staff members were observed not changing gloves or performing hand hygiene during catheter and wound care. Staff entered the resident's room without wearing gowns, and contaminated items were handled improperly, increasing the risk of infection. Resident 14 was on contact precautions, yet a staff member entered the room without wearing personal protective equipment (PPE) and handled the resident's food and water pitcher. Although another staff member noticed the breach and instructed the first staff member to wash hands and don PPE, the initial failure to follow protocol was a significant lapse in infection control practices. For Resident 12, who was cognitively intact and receiving insulin injections, a registered nurse administered the injection without wearing gloves, contrary to facility expectations. The nurse believed that regular handwashing negated the need for gloves, indicating a misunderstanding of infection control protocols. The Director of Nursing Services confirmed that wearing gloves for insulin administration is expected, highlighting a gap in staff training and adherence to infection control measures.
Delayed Transfer of Resident Trust Funds
Penalty
Summary
The facility failed to ensure the timely transfer of funds from resident trust accounts within 30 days following discharge for two residents. Resident 165 was discharged with a remaining account balance of $40.00, and Resident 166 passed away with a balance of $189.51. Both accounts were not closed within the required 30-day period. Staff Q, the Business Office Manager, confirmed the closure dates of the accounts, and Staff A, the Administrator, acknowledged the delay in issuing checks within the expected timeframe.
Failure to Report Allegation of Abuse for a Resident
Penalty
Summary
The facility failed to report an allegation of abuse, neglect, or mistreatment involving Resident 18, who was cognitively intact and had diagnoses including bipolar disorder, borderline personality disorder, major depressive disorder, and unspecified dementia. The incident occurred after Resident 18 experienced a fall approximately 7-8 weeks prior to the report, during which a nurse allegedly told the resident to get up despite their recent surgery and used the bed remote to make them sit up straight. Resident 18 did not report the incident at the time due to fear of getting into trouble. The Director of Nursing Services (DNS) was informed of the allegation on March 11, 2025, and acknowledged that the incident should have been reported and investigated at the time it occurred. A nursing progress note from July 20, 2024, documented an interaction where Resident 18 felt attacked during education on repositioning in bed, which may have been related to the incident. However, the facility's Accident and Incident log for July 2024 showed no entry regarding this incident. The Administrator confirmed that the expectation was for such incidents to be reported immediately for investigation.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately assess the Minimum Data Sets (MDS) for four residents, leading to discrepancies in their care plans and assessments. Resident 29 was documented as not using a wander/elopement alarm on their MDS, despite having a Wander Guard attached to their wheelchair as per the care plan and physician's order. Staff acknowledged the error in the MDS. Similarly, Resident 49's Admission MDS did not reflect the use of a wander guard, although it was documented in the electronic health record and confirmed by staff. Resident 13's Significant Change MDS failed to document refusals of care, despite progress notes and medication administration records indicating multiple refusals during the assessment period. Staff admitted there was no reason for the omissions. Resident 14's MDS assessments did not correctly identify significant weight loss, with staff using incorrect dates for weight comparisons. The errors were acknowledged by staff, who confirmed that the weight loss should have been coded on the MDS.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for three residents. Resident 53 was admitted with diagnoses including Major Depressive Disorder (MDD), Unspecified Psychosis, and Post Traumatic Stress Disorder (PTSD). However, the PASRR Level I only documented PTSD, omitting the other diagnoses. Staff D and Staff B acknowledged the omissions and confirmed that the PASRR was incorrect and should have been corrected. Resident 49's PASRR Level I documented a diagnosis of major depressive disorder but failed to include a diagnosis of psychotic disorder, despite the resident being treated with antipsychotic medication. Staff F acknowledged the inaccuracy and the need for a Level II evaluation referral. Resident 13's PASRR inaccurately included an anxiety disorder diagnosis, which was not present in the resident's health record. Staff D and Staff F confirmed the error, acknowledging that the anxiety disorder should not have been checked.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were reviewed, revised, and accurately reflected the care needs of five residents. Resident 51, who was cognitively intact and had diagnoses of schizophrenia and neurogenic bladder, had an indwelling catheter care plan that did not address the neurogenic bladder diagnosis. Additionally, the anxiety behavior monitoring care plan for Resident 51 lacked specificity regarding the resident's delusions and the appropriate staff response. Staff acknowledged that these care plans should have been more detailed and resident-specific. Resident 41, who required moderate assistance with oral care due to a right upper extremity deformity, reported being unable to brush their teeth without assistance. The care plan directed staff to set up oral care supplies and cue the resident, but it did not reflect the resident's increased need for physical assistance. Staff confirmed that the care plan needed updating to accurately reflect the resident's needs. Resident 49 had a care plan indicating a wander guard on the left wrist, but it was actually attached to the right ankle. Additionally, the care plan did not document the resident's need for nutritionally enhanced meals, despite a recommendation and order for such meals. Resident 38's care plan inaccurately documented their shower schedule, and Resident 14's nutrition care plan contained outdated interventions and lacked specific interventions for significant weight loss and food refusal. Staff interviews revealed that the care plans for these residents were not updated to reflect current needs and interventions. The deficiencies in care planning placed residents at risk for unmet care needs and diminished quality of life.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for five residents, leading to a deficiency in care. Resident 163, who was moderately cognitively impaired, had not received a shower for nine days despite requesting one and having a care plan that specified showers twice a week. The facility's records did not document any showers for this resident, and staff confirmed the lack of documentation and adherence to the care plan. Similarly, Resident 51, who was cognitively intact and required substantial assistance, reported not receiving scheduled baths, with records showing inconsistencies in the bathing schedule. Resident 41, who was cognitively intact, also experienced missed scheduled showers, with records indicating that bathing was offered on only five out of nine scheduled days. Resident 38, scheduled for showers twice a week, was only offered bathing on two out of nine scheduled days, with no refusals documented. Lastly, Resident 14, who was severely cognitively impaired and dependent on staff for personal hygiene, had not received a shower since February 24, 2025, despite being scheduled for showers twice a week. Staff confirmed the lack of adherence to the bathing schedule for these residents, indicating a systemic issue in providing necessary care.
Inadequate Documentation and Communication for Dialysis Care
Penalty
Summary
The facility failed to consistently document pre and post dialysis assessments and medications for a resident with end stage renal disease who required dialysis. The resident, who was moderately cognitively impaired, had specific orders for dialysis on Mondays, Wednesdays, and Fridays, including the administration of midodrine and Ceftazidime at the dialysis center. However, there was a lack of documentation for pre-dialysis evaluations on certain dates, and it was unclear whether the resident received the prescribed medications during dialysis sessions. The facility's contract with the dialysis center was outdated, and there was a lack of consistent communication and follow-up with the dialysis center regarding the resident's care. Staff members acknowledged the absence of necessary documentation and communication, which led to uncertainty about the resident's medication administration and care during dialysis. This deficiency placed the resident at risk for unmet care needs and potential medical complications.
High Medication Error Rate and Omitted Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 46.88% error rate during medication administration. This was observed in 15 out of 32 medication administration opportunities, affecting three residents. For Resident 6, medications such as Polyethylene Glycol, Duloxetine, Meloxicam, Doxycycline, and Loratadine were administered more than 60 minutes past their scheduled times. Similarly, Resident 12 received medications like Famotidine, Metoprolol, Vitamin D3, Eliquis, Gabapentin, Glipizide, Novolin N, Potassium Chloride, and Torsemide later than the allowed time frame. Staff R, an RN, was observed administering these medications late, and the Director of Nursing Services confirmed that this did not meet the facility's expectations. Additionally, Resident 57 did not receive the prescribed Breo Ellipta Inhalation Aerosol Powder for three consecutive days due to the medication being unavailable. Staff S, an LPN, was unable to locate the medication during a medication pass, and the Resident Care Manager acknowledged the omission without documentation of pharmacy contact or provider notification. These failures placed residents at risk for ineffective treatment and potential adverse outcomes.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured in a locked storage area and inaccessible to unauthorized staff and residents. During an observation of the Team 3 medication cart, a bottle of MiraLAX and a white pill in an unlabeled medication cup were found unattended on the cart. Staff R, an RN, admitted to leaving the MiraLAX out while using it and acknowledged that the pill should have been stored and labeled properly. On a separate occasion, a pill was observed on the cart in an unlabeled cup, which Staff S, an LPN, later disposed of in a sharps container. Additionally, an insulin pen was left unattended on the cart. Both the Resident Care Manager and the Director of Nursing Services confirmed that these practices did not meet the facility's expectations for medication storage. Furthermore, during a medication administration, Staff R placed an insulin pen on a resident's bedside table and left the room, leaving the medication unattended. Staff C, another Resident Care Manager, confirmed that medications should not be left at the bedside. These actions placed residents at risk for unauthorized access to medications, which could lead to medical complications and a diminished quality of life.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete, accurate, and accessible medical records for three residents, which placed them at risk for medical complications and unmet care needs. For Resident 60, who was moderately cognitively impaired and dependent on staff for all activities of daily living, there was no documentation in the electronic health record regarding the events leading up to his death or the notification of his family and provider. Staff members acknowledged the absence of necessary documentation, which was expected to be present. Resident 35, who was severely cognitively impaired, was taken to the hospital, but there was no progress note documenting his return to the facility. Staff confirmed the lack of documentation and stated that it was expected for nursing staff to document when a resident returned from the hospital, including any new diagnoses and orders. For Resident 13, who was severely cognitively impaired and dependent on staff, there was a lack of consistent skin assessments to monitor a documented pressure ulcer. The staging of the pressure ulcer was incorrectly done by an LPN, and there was a lack of clarification with an RN, leading to inaccurate documentation.
Failure to Perform Complete CPR Due to Expired Certifications and Missing Equipment
Penalty
Summary
The facility failed to ensure that staff performed complete Cardio-Pulmonary Resuscitation (CPR) for a resident who was found unresponsive and had a physician's order for CPR. The deficiency was identified when a resident, who had a POLST form indicating full resuscitation, was found not breathing. Staff initiated chest compressions but failed to provide respirations due to missing equipment on the emergency cart, specifically the ambu bag. This failure to perform complete CPR placed residents at risk for serious injury, harm, impairment, or death and was determined to be an Immediate Jeopardy situation. The resident involved was admitted with diagnoses including a fracture of the left femur, Chronic Obstructive Pulmonary Disease, and Hypertension. The resident was alert and oriented and required staff assistance for activities of daily living. On the day of the incident, the resident was found unresponsive by a CNA who then called for help. Licensed staff responded and initiated chest compressions but did not administer breaths due to the absence of necessary equipment. Paramedics arrived and took over CPR, but the resident was pronounced dead shortly after. The investigation revealed that the CPR certifications for the staff involved had expired, and the facility had not ensured that all required staff maintained current certifications. Interviews with staff confirmed the lack of respirations during CPR and the absence of the ambu bag on the crash cart. The facility's administration acknowledged the deficiency and the risk it posed to residents who required CPR.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits within the first 30 days after admission for two residents, which is a requirement according to the facility's policy. Resident 11, who had diagnoses including Diabetes Mellitus, Chronic Kidney Disease (Stage 4), and Acquired Absence of the left lower leg, was readmitted to the facility but did not receive a physician's visit for 112 days after readmission. Resident 14, diagnosed with Chronic Systolic Heart Failure, was also readmitted to the facility and did not receive a physician's visit for 50 days after readmission. The deficiency was acknowledged by the facility's Administrator and Director of Nursing, who stated that the facility physician had been on leave and they were unable to secure physician coverage during that time. As a result, residents were seen by Nurse Practitioners or Physician's Assistants instead of a physician, leading to the failure to meet the required physician visit schedule for Residents 11 and 14.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan and implement new interventions after a resident experienced a fall. The resident, who was admitted with diagnoses including dementia, psychosis, and a fractured right femur, was identified as being at high risk for falls. Despite this, after an unwitnessed fall resulting in a right femoral neck fracture, the care plan was not revised with interventions to prevent further falls. The facility's falls policy required post-fall actions to include reviewing and updating the care plan with newly identified interventions, which was not done in this case. Staff acknowledged the oversight in not updating the care plan.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to ensure an abuse allegation was reported timely for a resident with dementia and depression. The incident involved a CNA, Staff C, who allegedly grabbed the resident by the shirt, pulled him forward, and slapped him on the left upper arm. The incident was witnessed by two other CNAs, Staff D and Staff E, who did not report the incident until the following day. This delay in reporting prevented immediate investigation and intervention. The resident was admitted with cognitive impairment and did not exhibit behaviors or have extremity impairments according to the Quarterly Minimum Data Set. Despite the serious nature of the allegation, the facility's investigation and staff interviews were not conducted until the day after the incident. Staff C continued to work in the facility until the incident was reported to administration. The Director of Nursing confirmed that the expectation was for all staff to report abuse allegations immediately, which did not occur in this case.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
